SABBATICAL MEDICAL LEAVE
APPLICATION FOR SABBATICAL MEDICAL LEAVE
UNDER LOUISIANA REVISED STATUTE17:1170 et. seq.
EastBaton RougeParishSchool Board
Post Office Box 2950; Baton Rouge, LA70821
Telephone: (225) 922-5468; Fax: (225) 922-5688
IMPORTANT: This application must be sent by certified mail to the attention of the Superintendent not less than sixty (60) calendar days prior to the starting date for which this sabbatical medical leave application is made, when possible. Should an applicant become ill during a semester, the request must be sent by certified mail to the attention of the Superintendent as soon as possible.
NAME ______
Last First MI
MAILING ADDRESS ______
NumberStreetApt. Number
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CityStateZip Code
ALTERNATE ADDRESS DURING LEAVE: ______
CURRENT PHONE NUMBER: ______CELL PHONE: ______
EXACT PERIOD FOR WHICH LEAVE IS REQUESTED______
EMPLOYEE NUMBER:______SCHOOL: ______
List the consecutive semesters of active service in the EastBaton RougeParishSchool System (Ex. 1/94-95 through 2/98-99)
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Applicant’s date of birth ______
Please state the exact manner in which the requested sabbatical leave will be spent:
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______
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I, the undersigned applicant, do hereby acknowledge that, if this sabbatical leave is granted, I will be paid a salary equal to sixty-five percent (65%) of the salary [which is fixed at the inception of the sabbatical leave and will not change during the period of said sabbatical leave] that I would receive if I were employed full-time by the East Baton Rouge Parish School System at the beginning of the period of this sabbatical leave. I hereby affirm that I will comply with all policies and regulations of the East Baton Rouge Parish School System and the laws of the State of Louisiana regarding sabbatical leave enumerated in Title 17 of the Louisiana Revised Statutes, as amended.
As a condition of this sabbatical leave and to be eligible for compensation during such leave, I, the undersigned applicant, do hereby agree to return to service in the East Baton Rouge Parish School System for one (1) semester for each semester of sabbatical medical leave which I may be granted herein, and that such service shall begin immediately at the expiration of the sabbatical medical leave period herein requested.
I further acknowledge that I am prohibited during the period of this sabbatical leave, if granted, to be employed gainfully for more than twenty (20) hours per week unless such work meets all of the requirements of Louisiana Revised Statute 17:1177, and has been approved by the Board of the East Baton Rouge Parish School System. I further acknowledge that I am prohibited by state law [La. R.S. 17:1177(C)] from being employed during the period of this sabbatical medical leave, if granted, by any public or non-public school system within the United States of America, its territories or possessions.
I further affirm that all statements and representations made herein are true, accurate and correct to the best of my knowledge and belief.
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APPLICANT’S SIGNATURE DATE OF COMPLETION OF THIS FORM
TO BE COMPLETED BY THE OFFICE OF HUMAN RESOURCES
Years of employment verified
Certification during years in EBRPSS verified
Physician statement with all sections completed has been received
VERIFIED BY: ______DATE: ______
APPROVAL SIGNATURE: ______DATE: ______
A STATEMENT FROM A PHYSICIAN ATTESTING TO THE NEED FOR THE SABBATICAL MEDICAL LEAVE MUST BE PROVIDED ON THE ATTACHED FORM AND SENT DIRECTLY BY THE PHYSICIAN TO THE EASTBATONROUGEPARISHSCHOOL BOARD OFFICE. ALL SECTIONS OF THE FORM MUST BE COMPLETED FOR APPROVAL.
SABBATICAL MEDICAL LEAVE
PHYSICIAN’S STATEMENT AS REQUIRED BYLOUISIANA REVISED STATUTE 17:1170 et. seq.
EastBaton RougeParishSchool Board
Post Office Box 2950; Baton Rouge, LA70821
Telephone: (225) 922-5468; Fax: (225) 922-5688
THE INFORMATION CONTAINED IN THIS DOCUMENT IS EXEMPT FROM THE PUBLIC
RECORD LAWS OF THE STATE OF LOUISIANA. PLEASE PRINT OR TYPE
ALL SECTIONS OF THIS FORM MUST BE COMPLETED FOR APPROVAL
NAME OF PATIENT______
EMPLOYEE NUMBER ______SCHOOL ______
MAILING ADDRESS ______
NumberStreetCityStateZip Code
ALTERNATE ADDRESS DURING LEAVE: ______
CURRENT PHONE NUMBER: ______CELL PHONE: ______
EXACT PERIOD FOR WHICH LEAVE IS REQUESTED______
PHYSICIAN’S NAME: ______PHYSICIAN’S PHONE NUMBER: ______
Please complete the following request for information by circling YES or NO and providing a brief response if appropriate:
- Have you examined and/or treated this patient during the past two years?YesNo
- Current diagnosis and date of said diagnosis:______
______
- Based on your current diagnosis:
(a)Would this condition be considered within the parameters of a contagious
or communicable disease? Yes No
(b)Would this condition normally cause the patient to be hospitalized?YesNo
(c)Is recuperation from the effects of this condition possible? YesNo
(d)Does this condition reduce the patient’s capabilities in the following areas?
(1) VisionYesNo
(2)HearingYesNo
(3)SpeechYesNo
(4)MotionYesNo
(e)Does this condition prohibit the patient from conducting normal cognitive processes?YesNo
(f)Would this condition prohibit the patient from conducting the duties of a teacher?YesNo
As a licensed physician, please state HOW this condition limits the employee from performing the essential function(s) of his/her job description.
______
______
______
Describe the regimen of treatment to be prescribed indicating the number of visits, general nature and duration of treatment to include referrals to other health care providers.
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Please provide any other information, which you feel, would be pertinent in the School Board’s decision process as to whether or not to grant the sabbatical medical leave request made by the patient.
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Based on your diagnosis, could this patient be gainfully employed in any other job or occupation on a part-time basis (20 hours a week or less) during the period of this sabbatical medical leave?
YesType of Employment: ______ No
If YES, please explain in detail why this employee can perform this type of employment and not their current duties and responsibilities as a teacher. Add additional pages as needed.
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I, the undersigned, hereby affirm that I am a physician licensed under the laws of the State of Louisiana (or the state of domicile, if different from Louisiana). I further certify under penalty of criminal prosecution [La. R.S. 14:125] that I have examined the herein named patient/applicant for medical leave sabbatical and have found that the medical condition stated above makes the leave applied for herein medically necessary.
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SIGNATURE OF PHYSICIAN (ORIGINAL SIGNATURE ONLY – NO FACSIMILE)
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DATE SIGNED
PLEASE MAIL THIS FORM DIRECTLY TO THE SCHOOL BOARD OFFICE
AT THE ADDRESS GIVEN ABOVE
OHR Revised 2007 07